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Abstract: We investigated pre-exposure prophylaxis (PrEP) uptake, adherence, and discontinuation among young app-using men who have sex with men in California (N = 761). Approximately, 9.7% of participants had ever used PrEP; 87% of those deemed good candidates for screening (indicated by a Centers for Disease Control and Prevention risk index score ≥10) were not current or past users. PrEP use was associated with higher income [adjusted odds ratio (aOR): 4.13; confidence interval (CI): 1.87 to 9.12], receptive condomless anal sex (aOR: 3.41; CI: 1.71 to 6.78), HIV-positive sex partners (aOR: 2.87; CI: 1.53 to 5.38), popper use (aOR: 3.47; CI: 1.96 to 6.13), and recent sexually transmitted infection diagnosis (aOR: 2.90; CI: 1.64 to 5.13). Some users (41.5%) wanted help remembering to take PrEP. The top reason for discontinuation was concern about long-term side effects (33.0%). Young men who have sex with men app users are prime candidates for PrEP, despite low uptake. Apps may be useful tools for PrEP information dissemination, adherence monitoring, and support.

*Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, CA;

Supported by California HIV/AIDS Research Program (CHRP; Grant RP15-LA-007); the Center for HIV Identification, Prevention, and Treatment (CHIPTS; NIMH Grant MH58107); the UCLA Center for AIDS Research (CFAR; NIAID Grant AI028697); and the National Center for Advancing Translational Sciences through UCLA (CSTI; Grant UL1TR000124). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

INTRODUCTION

Across the US, cities, counties, and states are developing plans for “Getting to Zero” new HIV infections.1,2 These plans rely on 2 strategies: (1) routinizing HIV testing in high-risk communities, linking to care those who test positive, and suppressing viral load among those who are already HIV-positive; and (2) avoiding new infections using a variety of prevention approaches, such as pre-exposure prophylaxis (PrEP). Unfortunately, although much is known about increasing and sustaining engagement in HIV care, less is known about uptake of, adherence to, and the factors that support or hinder long-term use of PrEP.3

In California, as elsewhere in the US, HIV incidence is increasing among young men who have sex with men (YMSM), especially YMSM of color.4 Recent estimates attribute two-thirds of all new HIV infections to men who have sex with men (MSM),4,5 with nearly one-third of those infected aged 20–29 years.4 Studies suggest that YMSM who use geosocial networking apps (GSN apps) may be at increased risk for HIV6 because of their having higher numbers of sex partners,7 more frequent condomless anal sex (CAS),8–10 and greater incidence of sexually transmitted infections (STIs)7,10,11 compared to those who do not use GSN apps.

Although some research into willingness to engage in PrEP has focused on GSN app users,12 there are relatively few studies that measure PrEP uptake in this demographic, and research examining PrEP usage has been largely limited to participants in clinical settings.13–17 Although PrEP uptake is increasing, overall estimates remain low, with previous studies finding fewer than 5% of sampled MSM having ever taken it.18–24 These estimates, however, are mostly based on findings from studies in eastern cities,23,25,26 leaving estimates on PrEP uptake among YMSM in California—the state with the largest number of new HIV infections each year27—largely unknown.

Although PrEP is recommended by the Centers for Disease Control and Prevention (CDC) for high-risk MSM,28 past studies document numerous barriers to uptake among YMSM, including cost, availability, and fears of risk compensation (ie, increased risk behavior triggered by decreased perception of risk).29–31 Data from clinical trials suggest factors influencing PrEP use and adherence are not well-identified,32 and questions remain about how to motivate uptake of and sustain adherence to PrEP for HIV prevention.33 This study sought to understand current rates and correlates of PrEP uptake, adherence, and discontinuation among YMSM who use GSN apps.

METHODS

Participants and Procedures

This analysis used data from an online survey conducted from July 9 to August 20, 2015. Participants were recruited through several popular GSN apps using pop-up messaging and banner ads targeting users aged 18–29 years in California. YMSM interested in the study completed an eligibility screener confirming they were HIV-negative, a California resident, and between 18 and 29 years; it also confirmed their sex at birth as male and that they had male sex partners within the past 5 years. Completing the survey took approximately 20 minutes. Participants were compensated with $20 electronic gift cards for their time. All study procedures were approved by the UCLA North Campus Institutional Review Board.

Measures

The survey queried demographic information, including race/ethnicity, age, gender identity, sexual orientation, sexual behavior, current employment, highest level of education, annual income, current insurance coverage, homelessness in the past 12 months, and US citizenship. Questions regarding sexual risk behavior in the past 6 months included number of male sexual partners, number of instances of receptive CAS, and insertive CAS with an HIV-positive partner, number of HIV-positive partners, and ever exchanging sex for money. Other risk factors measured were STI diagnoses in the past year, substance use in the last 6 months, last HIV/STI test, and perceived risk for and concern about contracting HIV.

Using 6 of these risk measures, we calculated the MSM risk index based on the CDC's recommendations.34 This risk index considers age, number of male partners, HIV-positive partners, receptive CAS, insertive CAS with an HIV-positive partner, and methamphetamine use as factors in calculating a risk score (which can range from 0 to 45). Those with scores ≥10 on this scale warrant evaluation for intensive HIV prevention services, including PrEP. Participants were also asked if they had ever taken PrEP. Those who had taken PrEP were asked if they were current users and about their experience using PrEP; those who had stopped taking PrEP were asked why.

Data Analysis

Bivariate χ2 tests were performed comparing demographics and risk behaviors of those who had ever versus those who had never taken PrEP to determine variables of interest for multivariate modeling. In cases where sample size was too small, Fisher exact test was performed. We used the Benjamini and Hochberg procedure, which ranks P-values from most to least significant, to control for false discovery at the 0.05 significance level.35 Statistically significant variables at the bivariate level were included in a multivariate logistic regression model of PrEP uptake; stepwise regression was used to arrive at the final model.

RESULTS

We screened 3868 survey respondents, of which 1777 met our inclusion criterion. Our final sample of complete surveys included 761 California MSM aged 18–29 years who were sexually active in the past 5 years and had never been diagnosed with HIV/AIDS. Less than 10% of participants (9.7%) reported ever taking PrEP, with 71.6% of those who had ever taken PrEP being current users. Mean participant age was 23 years (SD = 3.2) with a smaller percentage of younger participants (age 18–24 years) having ever taken PrEP (48.6%) compared to older participants (age 25–29 years) (63.2%, P < 0.05). The sample was racially/ethnically diverse, and there were no statistically significant differences in PrEP uptake by race/ethnicity. Most men were identified as gay (81.9%); among PrEP users, nearly all were gay identified (97.3%). Among those who had ever taken PrEP, 55.4% reported annual salaries ≥$30,000 compared to those who had never taken PrEP (28.5%). A higher percentage of those who had ever taken PrEP were currently insured (86.5%) compared to those who had never used PrEP (74.1%; P < 0.05).

In general, PrEP users engaged in higher levels of HIV-risk behavior than non-PrEP users. A greater percentage of those who had ever used PrEP reported 6 or more sexual partners within the past 6 months (71.6%) compared to those who had never used PrEP (37.0%; P < 0.001). Similarly, greater percentages of PrEP users reported recent receptive CAS (82.4%) and insertive CAS with an HIV-positive partner (43.2%) than those who had never taken PrEP (52.4% and 22.0%, respectively; P < 0.001). Higher percentages of PrEP users reported using poppers (63.5% vs. 21.5%) and other illicit drugs in the last 6 months (41.9% vs. 16.9%; P < 0.001 in both cases) and testing positive for an STI within the past year (55.4% vs. 19.5%; P < 0.001) compared to those who had never taken PrEP. A full list of bivariate correlates of PrEP uptake is listed in Table 1.

Multivariate Correlates of PrEP Uptake

After adjusting for other variables in the model, those making ≥$30,000 had greater odds of being PrEP users compared to those making <$10,000 per year [adjusted odds ratio (aOR): 4.13, confidence interval (CI): 1.87 to 9.12, P < 0.001]. Receptive CAS in the last 6 months was positively associated with PrEP use (aOR: 3.41, CI: 1.71 to 6.78, P < 0.001). Those who reported sex with an HIV-positive partner in the last 6 months had greater odds of being PrEP users compared to those without an HIV-positive partner (aOR: 2.87, CI: 1.53 to 5.38, P = 0.001). YMSM who used poppers in the last 6 months had greater odds of being a PrEP user compared to those who did not use poppers (aOR: 3.47, CI: 1.96 to 6.13, P < 0.001). Finally, an STI diagnosis in the past year was associated with being a PrEP user (aOR: 2.90, CI: 1.64 to 5.13, P < 0.001). Table 2 contains multivariate results.

Reasons for PrEP Initiation and PrEP Adherence

For those who had ever taken PrEP (n = 74), the top 5 reasons for initiating PrEP were as follows: (1) wanting to worry less about getting HIV (71.6%), (2) having more than 1 sexual partner (66.2%), (3) not always using condoms (52.7%), (4) having sex with people whose HIV status the participant did not know (50.0%), and (5) disliking condoms (32.4%). Smaller percentages reported having PrEP recommended to them by a doctor or health care provider (29.7%), a friend (23.0%), or a sex partner (12.2%).

Among current PrEP users (n = 53), 92.5% reported taking PrEP 6–7 days per week. However, 41.5% indicated that they wanted help remembering to take PrEP. The average amount participants spent on PrEP, including clinical ancillary costs, was $88 monthly. Half (50.9%) received financial assistance and a quarter (24.5%) indicated wanting additional help paying for PrEP.

Reasons for Discontinuing PrEP

Among those who discontinued PrEP (n = 21), the top 5 reasons for discontinuing were as follows: (1) being concerned about the consequences of long-term PrEP use (33.3%), (2) being unable to afford a prescription for PrEP (28.6%), (3) using other strategies to reduce HIV risk (23.8%), (4) forgetting to take PrEP everyday (23.8%), and (5) being unable to afford the required medical visits for PrEP (19.0%).

DISCUSSION

PrEP implementation is crucial to advancing the goals of the National HIV/AIDS Strategy36 and forthcoming California statewide plan for “Getting to Zero.”37 Our study provides insights into current rates and correlates of PrEP uptake and reasons for initiation and discontinuation of PrEP among YMSM who use GSN apps. Overall, PrEP uptake remains low (9.7%), which is consistent with other studies of YMSM.18,23 Although uptake is increasing, much remains to be done to increase PrEP usage among this high-priority population.38

In our multivariate analysis, higher income was significantly associated with PrEP usage. These results, coupled with those indicating discontinuation of PrEP related to cost, underscore the need for programs and policies that offset the cost of taking PrEP. Programs that seek to enroll YMSM in insurance, along with co-payment assistance programs,39 are 2 strategies to reduce barriers among low-income YMSM. Several states, including New York, Colorado, and Washington, have implemented publicly funded programs to pay for PrEP—a strategy that ultimately may be cost-saving.40

The remaining correlates of PrEP uptake were related to individual risk behaviors, such as receptive CAS, sex with an HIV-positive partner, and popper use, which often accompanies high-risk sexual behaviors.41 Although these cross-sectional results do not necessarily represent risk compensation among PrEP users, they may indicate PrEP is reaching many YMSM who are good candidates, as both CAS and sex with HIV-positive partners are screening questions on the CDC's tool to evaluate for intensive HIV prevention services.28 The CDC tool omits popper use as a screening question, although recommended in predicting HIV incidence among MSM.34

Although not statistically significant in multivariate modeling, a greater percentage of PrEP users perceived themselves at high risk for HIV compared to non-PrEP users. These results point to the need for targeted strategies for identifying YMSM candidates for PrEP based on their risk perception and behavioral risk profile. In our study, 87% of those deemed good candidates for PrEP screening (indicated by a score ≥10 on the CDC risk index) were not current or past PrEP users. Although it is important to educate and encourage health providers to ask their patients about sexual risk and PrEP, using GSN apps to disseminate information regarding PrEP, including where to go for PrEP, is warranted.

Self-reported PrEP adherence was high in our sample (>90%)—efficacy studies with MSM show that PrEP can be up to 96% effective even when taken only 4 times weekly42—and may overestimate actual adherence, especially in light of the fact that nearly one-quarter of former users stated that difficulty remembering to take PrEP was a reason they discontinued it. Technology-supported adherence methods that have been successful in increasing antiretroviral adherence may also be leveraged to support PrEP adherence.43,44

This study is among the first to measure PrEP uptake among a sample of YMSM in California. Data point to the need for increasing PrEP uptake through targeted messaging to YMSM GNS app users engaged in high-risk sexual behaviors. Developing programs and policies that offset the cost for low-income YMSM is a high priority for increasing PrEP uptake. This sample is not representative of all YMSM who use GSN apps and all data relies on self-report. Further research using medical records to track PrEP uptake and/or more sophisticated measures of adherence is warranted. Despite limitations, this study points to the importance of increased outreach to YMSM using GSN apps for PrEP information dissemination and adherence monitoring and support.

12. Goedel WC, Halkitis PN, Greene RE, et al.. Correlates of awareness of and willingness to use pre-exposure prophylaxis (PrEP) in gay, bisexual, and other men who have sex with men who use geosocial-networking smartphone applications in New York city. AIDS Behav. 2016;20:1435–1442.

13. Cohen SE, Vittinghoff E, Bacon O, et al.. High interest in pre-exposure prophylaxis among men who have sex with men at risk for HIV-infection: baseline data from the US PrEP demonstration project. JAIDS. 2015;68:439–448.

14. Liu AY, Vittinghoff E, Chillag K, et al.. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. JAIDS. 2013;64:87–94.

20. Krakower DS, Mimiaga MJ, Rosenberger JG, et al.. Limited awareness and low immediate uptake of pre-exposure prophylaxis among men who have sex with men using an internet social networking site. PloS One. 2012;7:e33119.

23. Rucinski KB, Mensah NP, Sepkowitz KA, et al.. Knowledge and use of pre-exposure prophylaxis among an online sample of young men who have sex with men in New York City. AIDS Behav. 2013;17:2180–2184.

26. Dolezal C, Frasca T, Giguere R, et al.. Awareness of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) is low but interest is high among men engaging in condomless anal sex with men in Boston, Pittsburgh, and San Juan. AIDS Educ Prev. 2015;27:289–297.

28. Center for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2014 Clinical Practice Guideline. Center for Disease Control and Prevention; 2014.

38. Center for Disease Control and Prevention. Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition—United States, 2015. Center for Disease Control and Prevention; 2015.